NIHD WHEN LEAN MEETS EBD Terri Zborowsky, PhD 05.18.2017
Terri Zborowsky, PhD, EDAC Nursing Certificate (RN) BID, MSc, PhD Interior Design Experience 20+ years (Interior Designer, Medical Planner, Medical Equipment Planner, Director of E&R at Ellerbe Becket) 3 years Research Associate at CHD Design Researcher, HGA Adjunct Instructor, Center for Spirituality & Healing & School of Nursing, U of MN Member, Nursing Institute for Healthcare Design (NIHD) Advisory Board Member, HERD Journal 5/18/2017 2
Agenda Evidence based Design/ Practice based Research Lean Case Studies Q&A
The Problem —the same one…
Healthcare Problems Simple Problem Complicated Problem Complex Problem Plesak, P. (2003). Complexity and the Adoption of Innovation in Healthcare.
HGA Case Study Merging Methods: Lean & EBD Pre-Design Schematic Development Documentation Post-Occupancy DISCOVER APPLY TEST/PREDICT VERIFY COMPARE Set Optional Standards Future-State Patient Experience LEAN PROCESS IMPROVEMENT Metrics Evaluation & Goals Gather Baseline/ Operational Models Big Questions Performance Report Current-State Data Rapid Prototyping Critical to Quality through Valid Methods Adjacencies Special Project Support Current-State Evaluation Strategic Space Program (if necessary) Test & Calculate DATA GATHERING Hypothesize Outcomes Collect Data Using Same Use Baseline Data to EBD Gather Baseline/ Advantages of Develop Future-State Pre-Design Methods; Current-State Data Future-State Models Compare Data Sets Methods, Prototypes, Verify Application of through Valid Methods with Baseline Data; & Test Hypotheses & Program Evidence Aid in Decision Making 7
Practice based Research Freihoefer, K. & Zborowsky, T. (2016). Making the Case for Practice-Based Research and the Imperative Role of Design Practitioners. HERD, XX, XX-XX. 5/18/2017 Edit / Turn footer on or off under "Insert: Header & Footer" | Choose Apply or Apply to All 8
Designing RHCSF: An EBD Approach HGA Case Study “ Critical needs are HGA Research Toolkit identified… to produce a Q uality outcome” Staff Survey: Shadowing Retrospective Data Patient/Family Survey: Questionnaires or Critical to Quality Users Collection Questionnaires or Focus Groups Needs Focus Groups Pre-Design Schematic Development Documentation Post-Occupancy DISCOVER APPLY TEST/PREDICT VERIFY COMPARE Staff Survey: Shadowing Retrospective Data Patient/Family Survey: Questionnaires or Users Collection Questionnaires or Impact of Design Focus Groups Focus Groups 9
Case Study #1 Staff Satisfaction Shadowing Retrospective Data Questionnaires Users Collection (HCAPHS) PROGRAM Charting Charting Charting • 11 Postpartum Rooms Nourish • 4 Antepartum Rooms Nurses’ Station Office Office Med Entry • 18 Level II NICU Beds Supply/ Wait Office Soiled Edu Clean • Newborn Nursery Charting WOW Alcove Nursery • Lactation Teaching Rm St. Elizabeth’s Hospital, Ministry Health Care Post-Partum Unit Build-out, 2012
Shadow Tool
Go to GEMBA (Data Collection) Rounding in Corridor Staff View Central Nurse Station Patient Nurse Server View Patient Room
HGA Benchmark Database Triangular Rural/Pods Pass-Through Supply Core Academic Unit A Unit B Unit C Unit D Unit E (1NS:10PR) (1:9) (1:2) (1:1) (1:1) 52% 49% 54% Patient Rooms 41% 45% 37% 40% 34% 30% 41% Charting Stations Medication & Supply 5% 6% 7% 4% included in NS Rooms 1% 3% 5% Support Rooms 5% 3% Corridor Traveling 9% 6% 10% 5% 7% Distance Traveled 2.53 miles 2.29 miles 2.44 miles 1.71 miles 1.87 miles
Predictive Analyses Generate Evaluations and Predictions to Inform Design Benchmark Decentralized Existing Unit Decentralized Prototype Current State Studies Prediction Patient Rooms 39% 45-54% +10-15% Charting Stations 43% 32-39% -4-8% Medication & Supply 5% 1-5% -0-3% Rooms Support Rooms 1% 2-5% -0-2% Traveling 13% 5-8% -4-8% Less time in nurses’ stations and traveling = more time in patient rooms. For 5 dayshift nurses, overall time saved traveling is approx. 2 to 4 hrs.
Prototype Testing: 2-hr shadow of RN rounding staff restroom Existing Unit: Current State busy, goes to another off the unit went to med room 7 times .5 miles; & nourishment 3 times for ≈15.25 min. ice/water/food of travel 28 Bed-Option Unit: Future State .23 miles; ≈7.5 min. of travel 56% decrease
Patient Experience Toolkit EBD – Mock-Up Simulations LEAN – CTQ Evaluation St. Elizabeth’s Hospital, Ministry Health Care Post-Partum Unit Build-out, 2012
Categorize Findings into Critical to Quality CTQ: Efficiency (Critical Needs) NEED 1: Patient discharge needs to be more efficient NEED 2: Staff needs a place to chart NEED 3: Staff needs to communicate with others NEED 4: Staff needs working environment that supports their safety NEED 5: Staff needs to focus patient care at the bedside CTQ: Efficiency (Quality Metrics) Patient d/c time increases Time at charting station increases Communication with others increases Staff incidents decrease Time engaged patient care at the bedside increases • Need quick, stand-up charting locations • Need sit down charting stations • Need to be less congested and noisy
3-Phased POE Travel Distances Post- Post- Post- Overall Frequency of Trips Occupancy Occupancy Occupancy 3 Months Average @ 3-months @ 8-months @ 12-months 8 Months 2.89 miles 2.04 miles 1.64 miles 2.08 miles 12 Months » Sign. reduction overtime ( p < 0.001)
Staff Questionnaire Results Enhances or Hinders ability to get the job done p *** p *** p *** Statistically Significant difference between Nurses’ Station and other areas ( p ***) St. Elizabeth’s Hospital, Ministry Health Care Post-Partum Unit Build-out, 2012
HCAHPS/IP Results Pre & Post Occupancy St. Elizabeth’s Hospital, Ministry Health Care Post-Partum Unit Build-out, 2012
Correlations Servers Work Performance R =.71 Job Satisfaction R =.59 Health & Well-being R =.47
Case Study #2 Staff Satisfaction Staff Focus Group & Shadowing Questionnaires Interviews Users East Coast Hospital
POE Process Quick Post Occupancy Evaluation 2 hour Focus Group with Managers/Supervisors 18 Interviews with Front-line Staff 5 hours of Shadowing 1. Study current inpatient unit to inform design decision of next project. 2. Uncover lessons learned from inpatient unit--What works for front- line staff, what doesn’t. 3. Evaluate the CtQ needs identified for the Hospital. 4. Provide report out summary ppt to share with the design team.
Original IP Critical to Quality Needs 1. CHARTING 5. PORTABLE DIAGNOSTICS - 1 : 4 Ratio (Med/Surg) - Central location for portables, easily accessible - 1 : 2 Ratio (ICU/CCU) - Option for private charting space 6. PATIENT TRANSPORT for ancillaries & MD's - Transport equipment on unit - HIPAA Compliant - Elevator, door, corridor width to support transport - Visualization from Charting to Rooms 7. NUTRITION 2. VISUALIZATION - Storage area for food trays - Caregiver-to-caregiver visibility - Family access to nourishment area - Visitor-to-caregiver visibility - Visibility to Patient in room (casual) 8. MEDICATIONS & PNEUMATIC TUBE - Visibility of multiple Patient Rooms across unit - Pyxis centrally located - Patients don't feel isolated - More than 1 P-Tube - Narcotic storage (1:24) in central Med Room 3. COLLABORATION - Space for collaboration outside room 9. STAFFING TO VARIABLE CENSUS - Limit noise from collaboration into Patient Rooms - Limit moving patients for staffing efficiency 4. SUPPLIES 10. REHAB THERAPY - In-Room Server for commonly - Area in room for Rehab therapy used supplies & linens - Central location for less frequently used items
Staff Questionnaire
24 beds/unit
REPORT OUT: INTERVIEWS
Report Out: Interviews General Questions Interviewed 1. Tell us what it is like to work at XXX? Nurses 2 Unit Technicians 1 Content Specific Questions 2. What design elements on the med/surg unit EVS 3 supports or detracts from your work flow? 3. Do you have enough privacy (audio/visual)? Unit Secretary 2 4. Can you find other staff (supplies/medications) when Material’s Mgmt Technicians 2 you need to? 5. Where does collaboration happen? IV Pump Manager 1 6. What distracts you at work? Lab Manager 1 7. What do patient’s complain about the most? Infection Control Nurse 1 8. Do you feel safe at work? 9. If you could change one design item on the unit, Pharmacist 1 what would it be? Pharmacy Technicians 2 Wrap-up Question Rehab (OT/PT) 2 10. What else would you like us to know?
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